By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by Horizon Blue Cross Blue Shield in New Jersey: PA Forms, Appeals Timeline & Success Strategies

Answer Box: Quick Path to Evrysdi Coverage

Evrysdi (risdiplam) requires prior authorization from Horizon Blue Cross Blue Shield of New Jersey and must be dispensed through their specialty pharmacy network. To get approved: (1) Have your neurologist submit a PA form with genetic SMA confirmation, motor assessments, and prior therapy documentation to Horizon's utilization management, (2) Fill through an in-network specialty pharmacy like Accredo or CVS Caremark Specialty, and (3) If denied, file an internal appeal within 180 days, followed by New Jersey's external review through IHCAP if needed.

First step today: Call Pharmacy Member Services at 1-800-370-5088 to confirm your plan's formulary status and get the current PA form.

Table of Contents

Plan Types & Coverage Implications

Horizon Blue Cross Blue Shield of New Jersey operates several plan types that affect how Evrysdi coverage works:

Health Insurance Marketplace Plans: These ACA-compliant plans follow standardized formularies with Evrysdi listed as Tier 3 (highest copayment tier). All require prior authorization and specialty pharmacy dispensing.

Classic and AMT Plans: Employer-sponsored plans that may have slightly different formulary tiers but maintain the same PA requirements. Some self-funded employer plans may require exclusive use of specific specialty pharmacies like Accredo.

Horizon NJ Health (Medicaid): Separate formulary with 30-day quantity limits and age restrictions that may apply. Different PA criteria may be used compared to commercial plans.

Note: Network rules vary by plan type. HMO plans may require specialist referrals before PA submission, while PPO plans typically allow direct specialist consultation.

Formulary Status & Tier Placement

Current Status (2025): Evrysdi is covered on Horizon BCBSNJ formularies but classified as Tier 3 (non-preferred brand), meaning the highest copayment or coinsurance applies. The drug is subject to utilization management including prior authorization and is not excluded despite its specialty status.

Coverage at a Glance

Requirement Details Where to Find It Source
PA Required Yes, for all plans Horizon Medical Policy #193 Medical Policy
Formulary Tier Tier 3 (highest cost-sharing) 2025 Marketplace Formulary Plan Documents
Quantity Limits 30-day supply (Medicaid) Horizon NJ Health Limitations Medicaid Policy
Specialty Pharmacy Required Specialty Network List Network Directory
Step Therapy May apply to specific cases Contact member services Plan-specific

Formulary Updates: Horizon updates formularies quarterly. The most recent changes occurred in October 2024, but Evrysdi's status remained consistent.

Prior Authorization Requirements

Based on Horizon BCBSNJ Medical Policy #193, your neurologist must demonstrate that Evrysdi meets specific medical necessity criteria:

Key Approval Criteria

Diagnosis Requirements:

  • Confirmed spinal muscular atrophy (SMA) diagnosis through genetic testing
  • Documented SMN1 gene mutations (biallelic pathogenic variants)
  • SMA type classification (I, II, or III)

Clinical Documentation:

  • Motor function assessments using validated scales (CHOP-INTEND for infants, HFMSE for older patients)
  • Current weight and body surface area for dosing calculations
  • Baseline neurological status

Treatment History:

  • Documentation of prior SMA therapies (if any) and outcomes
  • Reasons why patient is not on concomitant Spinraza (nusinersen) or gene therapy
  • Contraindications to alternative treatments if applicable

Prescriber Requirements:

  • Must be prescribed by a neurologist or specialist experienced in SMA treatment
  • Ongoing monitoring plan must be documented
Tip: Include SMN2 copy number in genetic testing documentation, as this helps establish disease severity and prognosis.

Specialty Pharmacy Network

Mandatory Network Use: Evrysdi must be dispensed through Horizon's in-network specialty pharmacies to receive in-network benefits. Retail or standard mail-order pharmacies cannot fill this prescription with in-network coverage.

Approved Specialty Pharmacies

Pharmacy Name Phone Number Services
Accredo Health Group 866-515-1437 24/7 pharmacist access, home delivery
AllianceRx Walgreens Prime 866-823-9575 Condition-specific education, refill reminders
BioPlus Specialty Pharmacy 866-841-7142 Claims assistance, physician delivery
CVS Caremark Specialty 800-237-2767 Home delivery, monitoring support
Optum Pharmacy 855-427-4682 Comprehensive specialty services

Setup Process:

  1. Your doctor sends the prescription to one of these pharmacies
  2. The pharmacy contacts you to verify insurance and complete enrollment
  3. They handle PA submission if not already completed
  4. Once approved, they coordinate delivery and provide education
Important: Some self-funded employer plans may require exclusive use of Accredo or AllianceRx Walgreens Prime. Verify with member services before selecting a pharmacy.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage (Day 1)

Who: You or clinic staff
Action: Call Pharmacy Member Services at 1-800-370-5088
Documents: Insurance card, member ID
Timeline: Same day
Verify: Current formulary status, PA requirements, specialty pharmacy list

2. Gather Clinical Documentation (Days 1-3)

Who: Neurologist's office
Documents needed:

  • Genetic testing results showing SMN1 mutations
  • Motor function assessments (recent, within 90 days)
  • Prior therapy history and outcomes
  • Current weight and neurological status
  • Medical necessity letter

3. Submit Prior Authorization (Days 3-5)

Who: Prescribing neurologist
Method: Horizon provider portal or fax
Documents: PA form with all clinical documentation
Timeline: 5 business days for standard review

4. Select Specialty Pharmacy (Day 5)

Who: You or clinic
Action: Choose from approved network and provide prescription
Timeline: Same day setup, pending PA approval

5. Follow Up (Days 8-10)

Who: Clinic staff
Action: Check PA status, request peer-to-peer if needed
Escalation: Contact member services if delayed beyond timeline

6. Appeal if Denied (Within 180 days)

Who: You with clinic support
Method: Internal appeal first, then external review if needed
Timeline: 30 days for internal, 45 days for external

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Missing genetic confirmation Submit CLIA-certified genetic testing Lab report showing SMN1 mutations
Inadequate motor assessment Provide validated scale scores CHOP-INTEND, HFMSE, or age-appropriate assessment
Concurrent therapy concern Clarify treatment plan Letter explaining why not on Spinraza/Zolgensma
Dosing documentation gaps Submit weight-based calculations Current weight, BSA, dosing rationale
"Not medically necessary" Enhanced medical necessity letter Peer-reviewed studies, FDA labeling, clinical guidelines

Medical Necessity Letter Checklist

Your neurologist's letter should address:

  • Problem statement: SMA diagnosis with genetic confirmation
  • Prior treatments: What's been tried and outcomes
  • Clinical rationale: Why Evrysdi is appropriate now
  • Guideline support: FDA labeling, SMA care guidelines
  • Monitoring plan: How response will be assessed

Appeals Process in New Jersey

Internal Appeals with Horizon

Timeline: 180 days from denial to file
Process: Submit appeal letter with denial notice and supporting documentation
Decision: 30 days for standard, 72 hours for expedited
Contact: Member services or provider portal

External Review Through IHCAP

If internal appeals are unsuccessful, New Jersey's Independent Health Care Appeals Program (IHCAP) offers external review.

Eligibility: Completed internal appeals for fully-insured NJ plans
Timeline: 4 months from final denial to file
Cost: Free to patients
Success Rate: Approximately 50% of external appeals favor patients

How to File:

  • Online: Maximus NJ IHCAP Portal
  • Phone: 1-888-393-1062
  • Required: External appeal application, denial letters, medical records

Decision Timeline:

  • Standard review: 45 days
  • Expedited review: 48 hours for urgent cases
  • Binding on insurance company
From our advocates: "We've seen cases where external reviewers overturned denials when the internal appeal included new clinical data showing disease progression. The key was demonstrating that Evrysdi's oral administration was medically necessary given the patient's specific circumstances, such as spinal hardware making Spinraza infusions impossible."

Cost-Share Dynamics

As a Tier 3 drug, Evrysdi carries the highest cost-sharing under most Horizon plans. Your specific costs depend on:

  • Deductible: May need to be met before coverage begins
  • Coinsurance: Typically 30-50% for Tier 3 drugs
  • Out-of-pocket maximum: Annual limit on your costs

Cost-Saving Options:

  • Genentech Patient Foundation: Copay assistance and patient support
  • State pharmaceutical assistance programs
  • Manufacturer patient assistance programs for qualifying patients
Note: This information is educational only. Consult your plan documents or member services for specific cost-sharing details.

When to Escalate

Contact New Jersey Department of Banking and Insurance if:

  • Horizon fails to meet appeal timelines
  • You believe the denial violates state insurance laws
  • You need help understanding your rights

DOBI Consumer Hotline: 1-800-446-7467
IHCAP Information: 1-888-393-1062

File a complaint if you experience:

  • Unreasonable delays in PA processing
  • Denial of expedited review for urgent cases
  • Failure to provide required appeal information

FAQ

How long does Horizon BCBS PA take in New Jersey?
Standard PA decisions are made within 5 business days. Expedited reviews (for urgent cases) are processed within 72 hours.

What if Evrysdi is non-formulary on my specific plan?
Request a formulary exception with your neurologist. Include clinical justification for why formulary alternatives are inappropriate.

Can I request an expedited appeal?
Yes, if a delay would seriously jeopardize your health or ability to regain maximum function. Document the urgency in your appeal.

Does step therapy apply if I've failed treatments outside New Jersey?
Prior therapy failures from other states should be documented and included in your PA submission to support medical necessity.

What happens if my appeal is approved but I've already started treatment?
If you received treatment pending appeal, Horizon may provide retroactive coverage. Keep all receipts and documentation.

Can my doctor file appeals on my behalf?
Yes, providers can file external appeals with your written consent. This is often more efficient for complex cases.

About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Evrysdi. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific payer requirements and improve approval rates for patients and clinicians.

When navigating complex PA requirements for rare disease treatments, having expert support can make the difference between approval and prolonged delays. Counterforce Health helps ensure your appeal addresses the exact criteria that Horizon BCBS reviewers are looking for, increasing your chances of a successful outcome.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Horizon Blue Cross Blue Shield of New Jersey and consult with your healthcare provider for medical decisions. For official appeals guidance, contact the New Jersey Department of Banking and Insurance or IHCAP directly.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.